Identifying health inequities using a health system performance assessment: findings from Germany

BACKGROUND: Reducing health inequities is an important goal of high-performing health systems. Therefore, health inequities need to be assessed systematically, continuously and for all relevant aspects of a health system. The tool “health system performance assessments” (HSPA) aims at monitoring and evaluation the achievement of predefined goals and therefore the overall performance of a national health system. The aim of this study was to identify health inequities using a national HSPA. METHODS: A pilot study for a national HSPA in Germany was conducted between 2020 and 2023. The underlying framework defined the health system goals (e.g., access, quality, population health) and the respective indicators. Equity analyses (e.g., age, gender, socioeconomic factors, geographical region, type of health insurance) were conducted for each indicator to highlight inequities. RESULTS: Inequities were found for all health system goals. For example, unmet needs (“access”) were higher among people in the lowest income quintiles and in suburban areas. Potentially inadequate medication among the elderly (“quality”) was found more often for women and people 85+ years. The prevalence of infectious diseases (“population health”) was higher among men. CONCLUSIONS: Using a national HSPA to discover health inequities can help identify these in all areas and for all goals of a health system and monitor their development over time. The systematic and continuous assessment within an HSPA is an important prerequisite for identifying and evaluating measures aiming at reducing health inequities. KEY MESSAGES: • A national health system performance assessment is useful for identifying and monitoring health inequities on a system level. • Health inequities (e.g., regarding age, gender, geographic region) were found for every goal of the German health care system.